Project Summary/Abstract The federal government has successfully stimulated the widespread adoption of electronic health records (EHRs), however these systems are not optimized for safety. Prior research on EHR safety has built a foundation of identifying and classifying specific types of EHR related errors. But we must now understand the underlying context and contributing factors that lead to EHR-facilitated medical errors. Other high-risk industries, like aviation, have focused on the conditions under which errors occur, and have often put technological systems in place to capture the context around errors. Aircraft flight data recorders, often referred to as black boxes, provide this for retrospective analysis of events. In healthcare, it is not sufficient to simply know that an error happened; we must understand the context in which the error occurred by observing errors as they unfold in front of the healthcare team in the electronic health record, and the technology now exists to facilitate this. In response to special emphasis notice (NOT-HS-16-009) our goal is to apply a human factors engineering approach to analyze recorded video of clinical EHR use to understand how related safety hazards happen and what EHR design elements contributed to the error. Our multidisciplinary team's significant experience in systematic analysis of patient safety event reports, determining patterns of error in clinical data, and EHR design and usability will ensure success. By leveraging recorded video data already in place from thousands of physicians and hundreds of locations, this study overcomes many barriers to studying EHR users in situ, and will accomplish the following: Specific Aim 1: Identify and characterize potential EHR-facilitated errors patterns from clinical EHR data, including wrong patient, wrong medication, and wrong route errors. Specific Aim 2: Analyze the context of the error through video review and systematically categorize errors to understand what lead to the EHR-facilitated errors. Specific Aim 3: Identify the specific EHR design elements facilitating the errors, create data-driven design guidelines and disseminate the findings to diverse stakeholders. At the conclusion of this project, the team will have demonstrated the feasibility of using an automated video capture methodology, similar to the flight black box, to link specific EHR design elements to medical errors.